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Understanding your lab results
Normal is not the same as optimal. Lab reference ranges are set to identify serious disease — not to identify the level at which you will feel well, have energy, protect your bones, and think clearly. Rose explains the difference for every key biomarker.
Rose
"I sat in a doctors office and was told my labs were completely normal. I had a TSH of 3.4, ferritin of 16, vitamin D of 24, and fasting glucose of 94. Every single one was within the standard range. Every single one was suboptimal for a woman going through perimenopause. This page is what I wish I had known before that appointment."
How to use this guide
For each biomarker you will see three columns: the standard reference range (what labs use), what most doctors accept as normal, and what optimal looks like for menopausal women specifically. Optimal is not a fringe concept — it is the level associated with feeling well, not just avoiding disease. Each marker also includes the exact words to use with your doctor if you want to discuss results that are normal but not optimal.
Important caveats before you read
Optimal ranges are clinical consensus, not law. The optimal targets on this page reflect menopause society guidelines, functional medicine consensus, and published research — but they are not always based on large randomised trials. They represent expert clinical experience of what levels are associated with feeling well and reducing long-term risk.
Single tests during perimenopause are unreliable. Hormone levels — estradiol, FSH, testosterone — fluctuate significantly day to day in perimenopause. A single result tells only part of the story. Symptoms and clinical picture matter as much as numbers.
Lab ranges vary slightly between laboratories. Reference ranges differ between labs and countries. Always interpret your results against the reference range printed on your own report.
This is educational context — not a diagnosis. Use this guide to understand your results and prepare better questions. Your doctor interprets results in the context of your full clinical picture, history, and symptoms.
Which labs to ask for
A comprehensive perimenopause and menopause panel should include: full thyroid panel (TSH, Free T4, Free T3, TPO antibodies, TgAb), full iron studies (ferritin, serum iron, TIBC, transferrin saturation), vitamin B12 and folate, vitamin D (25-OH), fasting glucose and insulin, HbA1c, full lipid panel, hsCRP, homocysteine, estradiol and FSH, total and free testosterone, SHBG, and RBC magnesium. Most GPs will not run all of these routinely. Ask specifically. The doctor conversation guides on Rose include language for requesting these tests.
TSH (Thyroid Stimulating Hormone)
Standard range
0.4 - 4.5 mIU/L
Doctor accepts
Anything within the range
TSH above 2.0 is associated with fatigue, weight gain, brain fog, hair loss, and depression in symptomatic women — even when it falls within the technical normal range. Many women are told their thyroid is fine with a TSH of 3.5 and sent away with symptoms that have a treatable cause.
What to say to your doctor
"My TSH is 3.2 — within range but above 2.0. Given my symptoms of fatigue and hair loss, can we discuss whether treating to a lower TSH target would help?"
Free T4
Standard range
0.8 - 1.8 ng/dL
Doctor accepts
Anything within the range
Optimal
Mid to upper half of range (1.1 - 1.8)
Free T4 is the storage form of thyroid hormone. Low normal T4 with a normal TSH can still indicate suboptimal thyroid function. TSH alone misses this.
What to say to your doctor
"My Free T4 is in the lower half of the range — can we also look at Free T3 to understand conversion?"
Free T3
Standard range
2.3 - 4.2 pg/mL
Doctor accepts
Often not tested at all
Optimal
Upper third of range (3.5 - 4.2)
T3 is the active thyroid hormone that cells actually use. Many women convert T4 to T3 poorly — especially under stress or with nutritional deficiencies. Normal T4 with low T3 explains persistent symptoms when standard thyroid tests appear normal.
What to say to your doctor
"I would like Free T3 added to my thyroid panel — I understand it is not always tested routinely but it helps understand whether conversion is happening properly."
Thyroid Antibodies (TPO and TgAb)
Standard range
Negative or low
Doctor accepts
Often not tested unless TSH is abnormal
Hashimoto thyroiditis — the most common cause of hypothyroidism — is an autoimmune condition that can cause symptoms for years before TSH becomes abnormal. Antibodies are the early warning sign. Perimenopause frequently triggers or worsens autoimmune thyroid disease.
What to say to your doctor
"Can we test TPO and thyroglobulin antibodies? I understand Hashimoto can be present with normal TSH and I would like to rule it out given my symptoms."
Ferritin
Standard range
12 - 150 ng/mL
Doctor accepts
Above 12 — technically not deficient
Optimal
70 - 100 ng/mL for symptom-free function
Ferritin is the storage form of iron and the most sensitive marker of iron status. A ferritin of 14 is technically not anaemic — but a woman with ferritin of 14 will be exhausted, losing hair, struggling to concentrate, and cold all the time. The lower limit of the normal range is set for survival, not function.
What to say to your doctor
"My ferritin is 18 — technically in range but I understand optimal for energy and hair health is above 70. Can we discuss iron supplementation or investigation of why my ferritin is low?"
Serum Iron and Transferrin Saturation
Standard range
Iron: 60-170 mcg/dL. Saturation: 20-50%
Doctor accepts
Anything within range
Optimal
Iron: 80-130 mcg/dL. Saturation: 25-45%
These values alongside ferritin tell the full iron story. Low saturation with low ferritin confirms iron deficiency. Perimenopausal women with heavy periods are particularly at risk.
What to say to your doctor
"Can we run a full iron panel including serum iron, TIBC, and transferrin saturation alongside ferritin?"
Vitamin B12
Standard range
200 - 900 pg/mL
B12 deficiency causes fatigue, brain fog, tingling in hands and feet, and mood changes — symptoms that are almost identical to menopause. A B12 of 220 is technically not deficient but is well below the level needed for neurological health. Many women on metformin or PPIs have undiagnosed B12 deficiency.
What to say to your doctor
"My B12 is 240 — within range but below the 500 that research suggests is needed for optimal neurological function. Can we discuss supplementation?"
Vitamin D (25-OH)
Standard range
20 - 100 ng/mL (sufficient above 20)
Doctor accepts
Above 20 ng/mL
The sufficiency threshold of 20 ng/mL was set to prevent rickets. Optimal for bone density protection, immune function, mood, and cancer prevention is considerably higher. A vitamin D of 22 is technically sufficient and functionally inadequate. Most women in northern latitudes are well below optimal without supplementation.
What to say to your doctor
"My vitamin D is 28 — sufficient but well below the 60-80 that research suggests is optimal for bone density and immune function at menopause. Can we discuss a supplementation dose to bring this to optimal?"
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Blood Sugar and Metabolic Health
Fasting Glucose
Standard range
70 - 99 mg/dL (under 5.6 mmol/L)
Doctor accepts
Under 100 mg/dL
Pre-diabetes is defined as fasting glucose 100-125. But insulin resistance — and its consequences for weight, energy, and cardiovascular health — begins driving problems well before glucose rises above 100. A fasting glucose of 96 is not pre-diabetes but may indicate significant insulin resistance.
What to say to your doctor
"My fasting glucose is 95 — within normal range but I understand insulin resistance can be present before glucose rises above 100. Can we also test fasting insulin?"
Fasting Insulin
Standard range
2 - 25 uIU/mL
Doctor accepts
Often not tested unless glucose is elevated
Fasting insulin is the most sensitive early marker of insulin resistance — it rises years before fasting glucose does. A fasting insulin of 18 with a normal glucose means the pancreas is working very hard to keep glucose normal. That compensatory effort eventually fails. Insulin resistance also drives abdominal weight gain, hot flashes, and poor sleep.
What to say to your doctor
"I would like fasting insulin added to my metabolic testing — I understand it is a more sensitive early marker of insulin resistance than glucose alone and it is not routinely tested."
HbA1c
Standard range
Under 5.7%
Doctor accepts
Under 5.7%
HbA1c reflects average blood sugar over 3 months. An HbA1c of 5.6 is technically normal — but combined with fasting insulin above 8, it tells a story of early metabolic stress worth addressing now rather than when it crosses the pre-diabetes threshold.
What to say to your doctor
"My HbA1c is 5.5 — normal but trending upward. Given that metabolic risk increases at menopause, can we discuss preventive dietary and lifestyle approaches?"
Estradiol (E2)
Standard range
Varies widely by cycle phase and menopausal status
Doctor accepts
Any value with reference to menopausal range
Optimal
Depends on stage and whether on HRT
A single estradiol measurement during perimenopause is almost meaningless — levels fluctuate enormously day to day. In postmenopause, estradiol should be low if not on HRT and within therapeutic range if on HRT. The value matters less than the symptoms.
What to say to your doctor
"I understand estradiol fluctuates significantly in perimenopause — can we discuss my symptoms alongside the lab value rather than treating the number in isolation?"
FSH (Follicle Stimulating Hormone)
Standard range
Postmenopause: above 25-30 IU/L
Doctor accepts
Used to confirm menopause
Optimal
Context dependent
FSH rises as the ovaries produce less estrogen. A high FSH is one of the confirmatory markers of menopause — but it fluctuates in perimenopause and a single normal result does not rule out perimenopause. Two FSH measurements above 40 IU/L taken 4-6 weeks apart are required to confirm POI.
What to say to your doctor
"My FSH was normal on one test — I understand that FSH fluctuates in perimenopause and a single normal result does not rule out perimenopause. Can we assess based on symptoms and timeline alongside labs?"
Testosterone (Total and Free)
Standard range
Total: 15-70 ng/dL in women
Doctor accepts
Often not tested in women
Optimal
Upper third of reference range for age
Testosterone declines with age and the decline accelerates at menopause. Low testosterone causes low libido, fatigue, reduced motivation, brain fog, and muscle loss — symptoms almost identical to low estrogen. It is rarely tested in women. Asking for it specifically opens a treatment conversation most doctors never initiate.
What to say to your doctor
"I would like total and free testosterone measured — I understand testosterone declines significantly at menopause and low levels cause fatigue, low libido, and brain fog that are often undertreated."
SHBG (Sex Hormone Binding Globulin)
Standard range
18 - 144 nmol/L
Doctor accepts
Rarely tested
Optimal
Context dependent — affects free hormone availability
SHBG binds to testosterone and estrogen, making them unavailable for use. High SHBG means less free testosterone and estrogen even if total levels appear adequate. Oral estrogen raises SHBG significantly — one reason transdermal estrogen is often preferred.
What to say to your doctor
"Can we test SHBG alongside testosterone? I understand it affects how much free testosterone is actually available and is important context for interpreting hormone levels."
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Inflammation and Cardiovascular
hsCRP (High-Sensitivity C-Reactive Protein)
Standard range
Under 3.0 mg/L
hsCRP is the most widely available marker of systemic inflammation. Chronic low-grade inflammation increases at menopause and drives cardiovascular disease, cognitive decline, and joint pain. A value of 2.5 is technically normal — but at the high end of a range associated with elevated cardiovascular risk.
What to say to your doctor
"My hsCRP is 2.3 — within normal range but I understand values above 1.0 are associated with elevated cardiovascular risk. Can we discuss anti-inflammatory lifestyle approaches?"
Homocysteine
Standard range
Under 15 umol/L
Elevated homocysteine is an independent risk factor for cardiovascular disease and cognitive decline — particularly relevant at menopause when both risks increase. It is easily treated with B vitamins (B12, B6, folate). Rarely tested routinely despite being highly actionable.
What to say to your doctor
"Can we add homocysteine to my cardiovascular risk assessment? I understand it is an independent risk factor that responds well to B vitamin treatment if elevated."
Full Lipid Panel
Standard range
LDL under 100, HDL above 50, Triglycerides under 150
Doctor accepts
Standard reference ranges
Optimal
LDL under 70 in high cardiovascular risk. HDL above 60. Triglycerides under 100.
LDL cholesterol rises significantly at menopause as estrogenic protection is withdrawn. Many women cross from optimal to borderline in the first years after menopause without anyone discussing it. Triglycerides above 100 with HDL below 50 suggests insulin resistance even if LDL appears acceptable.
What to say to your doctor
"My LDL has risen since menopause — can we discuss whether this warrants intervention and what my 10-year cardiovascular risk score is?"
DEXA Scan — T-score
Standard range
Normal: above -1.0. Osteopenia: -1.0 to -2.5. Osteoporosis: below -2.5
Doctor accepts
Treatment typically at -2.5 or below
Optimal
Above -1.0 — and protecting that through menopause
The T-score compares your bone density to a healthy 30-year-old. A T-score of -1.5 is osteopenia — not yet osteoporosis but heading there rapidly if menopause-related bone loss is not addressed. Many doctors wait until -2.5 before acting. Acting at -1.5 with HRT, calcium, D3, K2, and resistance training can prevent ever reaching -2.5.
What to say to your doctor
"My T-score is -1.4 — osteopenia rather than osteoporosis, but I understand bone loss accelerates at menopause and I would like to discuss preventive intervention now rather than waiting."
DEXA Scan — Z-score
Standard range
Normal: above -2.0
Doctor accepts
Rarely explained to patients
Optimal
Above 0 (average or above for your age)
The Z-score compares your bone density to women your own age. A Z-score of -1.0 means your bones are lower density than average for your age — which may indicate secondary causes of bone loss beyond menopause (thyroid, vitamin D, medication effects) that warrant investigation.
What to say to your doctor
"Can you explain both my T-score and Z-score? I understand the Z-score compares me to women my age and a low Z-score might indicate secondary causes worth investigating."
Magnesium — RBC (Red Blood Cell)
Standard range
4.2 - 6.8 mg/dL
Doctor accepts
Serum magnesium (which misses most deficiency)
Optimal
Upper half of RBC range (5.5 - 6.8)
Standard serum magnesium is one of the least useful lab tests in medicine — the body will strip magnesium from cells and bones to maintain serum levels, so serum can appear normal even when total body magnesium is significantly depleted. RBC magnesium is a more accurate measure of cellular magnesium status. Most labs only offer serum. Ask specifically for RBC magnesium.
What to say to your doctor
"I would like RBC magnesium rather than serum magnesium — I understand serum levels are maintained at the expense of cellular magnesium and are not a reliable indicator of true magnesium status."
Upload your results to Rose
Upload your blood panel results and Rose will review them against menopause-specific reference ranges and return personalised commentary. Results are deleted within 24 hours.
Rose on this
"The most empowering thing I did was stop accepting normal as good enough. Normal means you are not sick enough to require urgent intervention. Optimal means you are functioning well. Those are very different standards — and you are allowed to aim for the higher one."
From Rose
"Every woman deserves to understand her own results — not to be handed a piece of paper and told everything is fine when she knows she is not fine. Your labs are data about your body. You are entitled to understand them fully, question what is within range but not optimal, and advocate for the level of care that matches what the evidence says you need."
Written by
Rose
Navigating perimenopause · Researcher · Founded rosemyfriend.com
Research basis
PubMed · Cochrane reviews · NICE guidelines · British Menopause Society · The Menopause Society
Read methodology →
Rose provides evidence-graded educational information — not medical advice. Always discuss health decisions with a qualified healthcare provider.
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